CMS Issues Final Rule on Fire Safety Requirements for Health Care Facilities

May 5, 2016

The Centers for Medicare & Medicaid Services (CMS) published a final rule containing updated fire protection guidelines applicable to Medicare and Medicaid participating hospitals, critical access hospitals (CAHs), long term care facilities, inpatient hospice facilities, ambulatory surgical centers (ASCs), programs for all inclusive care for the elderly (PACE), religious non-medical healthcare institutions, and intermediate care facilities for individuals with intellectual disabilities (ICF-IIDs).  The guidelines are intended to promote the health and safety of patients and their families as well as facility staff.

The final rule incorporates updated provisions of the National Fire Protection Association’s (NFPA’s) 101® 2012 edition of the Life Safety Code and the NFPA’s 99® 2012 edition of the Health Care Facilities Code.  A summary of some of the major provisions is set forth below:

  • Health care facilities located in buildings taller than 75 feet must install automatic sprinkler systems within 12 years after the effective date of the rule.
  • Health care facilities must have a fire watch or building evacuation if their sprinkler systems are out of service for more than 10 hours in a 24-hour period.
  • Hospital outpatient surgical departments must meet the applicable provisions in the Ambulatory Health Care occupancy chapter of the 2012 edition of the Life Safety Code.
  • Long term care facilities are permitted to make the environment in the facility more home-like by including fixed seating in the corridor, decorations in patient rooms, such as pictures and other items of home décor, and fireplaces in smoke compartments without a one hour fire wall rating.
  • Cooking facilities may have an opening to the hallway door to allow residents of inpatient facilities, such as nursing homes, to make food for themselves or others, with appropriate supervision.
  • All doors to hazardous areas in ASCs must be self-closing or must close automatically.
  • ASCs may place alcohol based hand rub dispensers in corridors to provide easier access.
  • ICF-IICDs must install sprinklers in attics if the attics are used for living purposes, including storage and fuel fired equipment.
  • ICF-IICDs must install heat detection systems in attics that are not used for living purposes.

CMS may accept a state’s fire and safety code provisions instead of the provisions of the Life Safety Code if it determines that the state’s provisions are equivalent to or more stringent than the Life Safety Code provisions.  CMS also has the authority to grant waivers of specific provisions of the Life Safety Code if their application would result in unreasonable hardship for a facility, provided that the health and safety of the facility’s patients and staff would not be adversely affected.

Health care facilities affected by the final rule must comply with its provisions within 60 days of its publication in the Federal Register, or by July 5, 2016, unless an exception applies or a facility obtains a waiver of specific provisions.

If you have any questions regarding the final rule on fire safety requirements for health care facilities, please contact Rochelle H. Zapol, chair of the firm’s Health Care Practice Group and the author of this alert. You can reach Rochelle at 617 456 8036 or  

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